Bronson Battle Creek

All Charges

Charge

Type

Setting

Price

GABAPENTIN 300 MG CAPSULE

Facility

$277.30

Service Code	NDC 63739090310
Hospital Charge Code	18308
Hospital Revenue Code	637
Min. Negotiated Rate	$110.92
Max. Negotiated Rate	$249.57
Rate for Payer: Aetna Commercial	$235.71
Rate for Payer: Aetna Medicare	$138.65
Rate for Payer: Aetna New Business (MI Preferred)	$180.25
Rate for Payer: BCBS Complete	$110.92
Rate for Payer: Cash Price	$221.84
Rate for Payer: Cofinity Commercial	$194.11
Rate for Payer: Cofinity Commercial	$238.48
Rate for Payer: Cofinity Medicare Advantage	$194.11
Rate for Payer: Encore Health Key Benefits Commercial	$221.84
Rate for Payer: Healthscope Commercial	$249.57
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$235.71
Rate for Payer: PHP Commercial	$235.71
Rate for Payer: Priority Health Cigna Priority Health	$180.25
Rate for Payer: Priority Health SBD	$174.70

GABAPENTIN 300 MG CAPSULE

Facility

$230.30

Service Code	NDC 63739023610
Hospital Charge Code	18308
Hospital Revenue Code	637
Min. Negotiated Rate	$92.12
Max. Negotiated Rate	$207.27
Rate for Payer: Aetna Commercial	$195.75
Rate for Payer: Aetna Medicare	$115.15
Rate for Payer: Aetna New Business (MI Preferred)	$149.69
Rate for Payer: BCBS Complete	$92.12
Rate for Payer: Cash Price	$184.24
Rate for Payer: Cofinity Commercial	$161.21
Rate for Payer: Cofinity Commercial	$198.06
Rate for Payer: Cofinity Medicare Advantage	$161.21
Rate for Payer: Encore Health Key Benefits Commercial	$184.24
Rate for Payer: Healthscope Commercial	$207.27
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$195.75
Rate for Payer: PHP Commercial	$195.75
Rate for Payer: Priority Health Cigna Priority Health	$149.69
Rate for Payer: Priority Health SBD	$145.09

GABAPENTIN 300 MG CAPSULE

Facility

$277.30

Service Code	NDC 63739090310
Hospital Charge Code	18308
Hospital Revenue Code	637
Min. Negotiated Rate	$174.70
Max. Negotiated Rate	$249.57
Rate for Payer: Aetna Commercial	$235.71
Rate for Payer: Aetna New Business (MI Preferred)	$180.25
Rate for Payer: Cash Price	$221.84
Rate for Payer: Cofinity Commercial	$194.11
Rate for Payer: Cofinity Commercial	$238.48
Rate for Payer: Cofinity Medicare Advantage	$194.11
Rate for Payer: Encore Health Key Benefits Commercial	$221.84
Rate for Payer: Healthscope Commercial	$249.57
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$235.71
Rate for Payer: PHP Commercial	$235.71
Rate for Payer: Priority Health Cigna Priority Health	$180.25
Rate for Payer: Priority Health SBD	$174.70

GABAPENTIN 400 MG CAPSULE

Facility

$239.70

Service Code	NDC 63739098410
Hospital Charge Code	18307
Hospital Revenue Code	637
Min. Negotiated Rate	$95.88
Max. Negotiated Rate	$215.73
Rate for Payer: Aetna Commercial	$203.75
Rate for Payer: Aetna Medicare	$119.85
Rate for Payer: Aetna New Business (MI Preferred)	$155.81
Rate for Payer: BCBS Complete	$95.88
Rate for Payer: Cash Price	$191.76
Rate for Payer: Cofinity Commercial	$167.79
Rate for Payer: Cofinity Commercial	$206.14
Rate for Payer: Cofinity Medicare Advantage	$167.79
Rate for Payer: Encore Health Key Benefits Commercial	$191.76
Rate for Payer: Healthscope Commercial	$215.73
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$203.75
Rate for Payer: PHP Commercial	$203.75
Rate for Payer: Priority Health Cigna Priority Health	$155.81
Rate for Payer: Priority Health SBD	$151.01

GABAPENTIN 400 MG CAPSULE

Facility

$148.05

Service Code	NDC 67877022401
Hospital Charge Code	18307
Hospital Revenue Code	637
Min. Negotiated Rate	$59.22
Max. Negotiated Rate	$133.25
Rate for Payer: Aetna Commercial	$125.84
Rate for Payer: Aetna Medicare	$74.03
Rate for Payer: Aetna New Business (MI Preferred)	$96.23
Rate for Payer: BCBS Complete	$59.22
Rate for Payer: Cash Price	$118.44
Rate for Payer: Cofinity Commercial	$103.64
Rate for Payer: Cofinity Commercial	$127.32
Rate for Payer: Cofinity Medicare Advantage	$103.64
Rate for Payer: Encore Health Key Benefits Commercial	$118.44
Rate for Payer: Healthscope Commercial	$133.25
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$125.84
Rate for Payer: PHP Commercial	$125.84
Rate for Payer: Priority Health Cigna Priority Health	$96.23
Rate for Payer: Priority Health SBD	$93.27

GABAPENTIN 400 MG CAPSULE

Facility

$239.70

Service Code	NDC 63739098410
Hospital Charge Code	18307
Hospital Revenue Code	637
Min. Negotiated Rate	$151.01
Max. Negotiated Rate	$215.73
Rate for Payer: Aetna Commercial	$203.75
Rate for Payer: Aetna New Business (MI Preferred)	$155.81
Rate for Payer: Cash Price	$191.76
Rate for Payer: Cofinity Commercial	$167.79
Rate for Payer: Cofinity Commercial	$206.14
Rate for Payer: Cofinity Medicare Advantage	$167.79
Rate for Payer: Encore Health Key Benefits Commercial	$191.76
Rate for Payer: Healthscope Commercial	$215.73
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$203.75
Rate for Payer: PHP Commercial	$203.75
Rate for Payer: Priority Health Cigna Priority Health	$155.81
Rate for Payer: Priority Health SBD	$151.01

GABAPENTIN 400 MG CAPSULE

Facility

$148.05

Service Code	NDC 67877022401
Hospital Charge Code	18307
Hospital Revenue Code	637
Min. Negotiated Rate	$93.27
Max. Negotiated Rate	$133.25
Rate for Payer: Aetna Commercial	$125.84
Rate for Payer: Aetna New Business (MI Preferred)	$96.23
Rate for Payer: Cash Price	$118.44
Rate for Payer: Cofinity Commercial	$103.64
Rate for Payer: Cofinity Commercial	$127.32
Rate for Payer: Cofinity Medicare Advantage	$103.64
Rate for Payer: Encore Health Key Benefits Commercial	$118.44
Rate for Payer: Healthscope Commercial	$133.25
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$125.84
Rate for Payer: PHP Commercial	$125.84
Rate for Payer: Priority Health Cigna Priority Health	$96.23
Rate for Payer: Priority Health SBD	$93.27

GABAPENTIN 400 MG CAPSULE

Facility

$272.60

Service Code	NDC 00904666761
Hospital Charge Code	18307
Hospital Revenue Code	637
Min. Negotiated Rate	$109.04
Max. Negotiated Rate	$245.34
Rate for Payer: Aetna Commercial	$231.71
Rate for Payer: Aetna Medicare	$136.30
Rate for Payer: Aetna New Business (MI Preferred)	$177.19
Rate for Payer: BCBS Complete	$109.04
Rate for Payer: Cash Price	$218.08
Rate for Payer: Cofinity Commercial	$190.82
Rate for Payer: Cofinity Commercial	$234.44
Rate for Payer: Cofinity Medicare Advantage	$190.82
Rate for Payer: Encore Health Key Benefits Commercial	$218.08
Rate for Payer: Healthscope Commercial	$245.34
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$231.71
Rate for Payer: PHP Commercial	$231.71
Rate for Payer: Priority Health Cigna Priority Health	$177.19
Rate for Payer: Priority Health SBD	$171.74

GABAPENTIN 400 MG CAPSULE

Facility

$272.60

Service Code	NDC 00904666761
Hospital Charge Code	18307
Hospital Revenue Code	637
Min. Negotiated Rate	$171.74
Max. Negotiated Rate	$245.34
Rate for Payer: Aetna Commercial	$231.71
Rate for Payer: Aetna New Business (MI Preferred)	$177.19
Rate for Payer: Cash Price	$218.08
Rate for Payer: Cofinity Commercial	$190.82
Rate for Payer: Cofinity Commercial	$234.44
Rate for Payer: Cofinity Medicare Advantage	$190.82
Rate for Payer: Encore Health Key Benefits Commercial	$218.08
Rate for Payer: Healthscope Commercial	$245.34
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$231.71
Rate for Payer: PHP Commercial	$231.71
Rate for Payer: Priority Health Cigna Priority Health	$177.19
Rate for Payer: Priority Health SBD	$171.74

GABAPENTIN 600 MG TABLET

Facility

$441.80

Service Code	NDC 68462012601
Hospital Charge Code	25855
Hospital Revenue Code	637
Min. Negotiated Rate	$176.72
Max. Negotiated Rate	$397.62
Rate for Payer: Aetna Commercial	$375.53
Rate for Payer: Aetna Medicare	$220.90
Rate for Payer: Aetna New Business (MI Preferred)	$287.17
Rate for Payer: BCBS Complete	$176.72
Rate for Payer: Cash Price	$353.44
Rate for Payer: Cofinity Commercial	$309.26
Rate for Payer: Cofinity Commercial	$379.95
Rate for Payer: Cofinity Medicare Advantage	$309.26
Rate for Payer: Encore Health Key Benefits Commercial	$353.44
Rate for Payer: Healthscope Commercial	$397.62
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$375.53
Rate for Payer: PHP Commercial	$375.53
Rate for Payer: Priority Health Cigna Priority Health	$287.17
Rate for Payer: Priority Health SBD	$278.33

GABAPENTIN 600 MG TABLET

Facility

$228.00

Service Code	NDC 00904682361
Hospital Charge Code	25855
Hospital Revenue Code	637
Min. Negotiated Rate	$143.64
Max. Negotiated Rate	$205.20
Rate for Payer: Aetna Commercial	$193.80
Rate for Payer: Aetna New Business (MI Preferred)	$148.20
Rate for Payer: Cash Price	$182.40
Rate for Payer: Cofinity Commercial	$159.60
Rate for Payer: Cofinity Commercial	$196.08
Rate for Payer: Cofinity Medicare Advantage	$159.60
Rate for Payer: Encore Health Key Benefits Commercial	$182.40
Rate for Payer: Healthscope Commercial	$205.20
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$193.80
Rate for Payer: PHP Commercial	$193.80
Rate for Payer: Priority Health Cigna Priority Health	$148.20
Rate for Payer: Priority Health SBD	$143.64

GABAPENTIN 600 MG TABLET

Facility

$3.43

Service Code	NDC 42292002401
Hospital Charge Code	25855
Hospital Revenue Code	637
Min. Negotiated Rate	$1.37
Max. Negotiated Rate	$3.09
Rate for Payer: Aetna Commercial	$2.92
Rate for Payer: Aetna Medicare	$1.72
Rate for Payer: Aetna New Business (MI Preferred)	$2.23
Rate for Payer: BCBS Complete	$1.37
Rate for Payer: Cash Price	$2.74
Rate for Payer: Cofinity Commercial	$2.40
Rate for Payer: Cofinity Commercial	$2.95
Rate for Payer: Cofinity Medicare Advantage	$2.40
Rate for Payer: Encore Health Key Benefits Commercial	$2.74
Rate for Payer: Healthscope Commercial	$3.09
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$2.92
Rate for Payer: PHP Commercial	$2.92
Rate for Payer: Priority Health Cigna Priority Health	$2.23
Rate for Payer: Priority Health SBD	$2.16

GABAPENTIN 600 MG TABLET

Facility

$342.95

Service Code	NDC 42292002420
Hospital Charge Code	25855
Hospital Revenue Code	637
Min. Negotiated Rate	$216.06
Max. Negotiated Rate	$308.65
Rate for Payer: Aetna Commercial	$291.51
Rate for Payer: Aetna New Business (MI Preferred)	$222.92
Rate for Payer: Cash Price	$274.36
Rate for Payer: Cofinity Commercial	$240.06
Rate for Payer: Cofinity Commercial	$294.94
Rate for Payer: Cofinity Medicare Advantage	$240.06
Rate for Payer: Encore Health Key Benefits Commercial	$274.36
Rate for Payer: Healthscope Commercial	$308.65
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$291.51
Rate for Payer: PHP Commercial	$291.51
Rate for Payer: Priority Health Cigna Priority Health	$222.92
Rate for Payer: Priority Health SBD	$216.06

GABAPENTIN 600 MG TABLET

Facility

$3.43

Service Code	NDC 42292002401
Hospital Charge Code	25855
Hospital Revenue Code	637
Min. Negotiated Rate	$2.16
Max. Negotiated Rate	$3.09
Rate for Payer: Aetna Commercial	$2.92
Rate for Payer: Aetna New Business (MI Preferred)	$2.23
Rate for Payer: Cash Price	$2.74
Rate for Payer: Cofinity Commercial	$2.40
Rate for Payer: Cofinity Commercial	$2.95
Rate for Payer: Cofinity Medicare Advantage	$2.40
Rate for Payer: Encore Health Key Benefits Commercial	$2.74
Rate for Payer: Healthscope Commercial	$3.09
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$2.92
Rate for Payer: PHP Commercial	$2.92
Rate for Payer: Priority Health Cigna Priority Health	$2.23
Rate for Payer: Priority Health SBD	$2.16

GABAPENTIN 600 MG TABLET

Facility

$342.95

Service Code	NDC 42292002420
Hospital Charge Code	25855
Hospital Revenue Code	637
Min. Negotiated Rate	$137.18
Max. Negotiated Rate	$308.65
Rate for Payer: Aetna Commercial	$291.51
Rate for Payer: Aetna Medicare	$171.47
Rate for Payer: Aetna New Business (MI Preferred)	$222.92
Rate for Payer: BCBS Complete	$137.18
Rate for Payer: Cash Price	$274.36
Rate for Payer: Cofinity Commercial	$240.06
Rate for Payer: Cofinity Commercial	$294.94
Rate for Payer: Cofinity Medicare Advantage	$240.06
Rate for Payer: Encore Health Key Benefits Commercial	$274.36
Rate for Payer: Healthscope Commercial	$308.65
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$291.51
Rate for Payer: PHP Commercial	$291.51
Rate for Payer: Priority Health Cigna Priority Health	$222.92
Rate for Payer: Priority Health SBD	$216.06

GABAPENTIN 600 MG TABLET

Facility

$159.84

Service Code	NDC 50268035115
Hospital Charge Code	25855
Hospital Revenue Code	637
Min. Negotiated Rate	$100.70
Max. Negotiated Rate	$143.86
Rate for Payer: Aetna Commercial	$135.86
Rate for Payer: Aetna New Business (MI Preferred)	$103.90
Rate for Payer: Cash Price	$127.87
Rate for Payer: Cofinity Commercial	$111.89
Rate for Payer: Cofinity Commercial	$137.46
Rate for Payer: Cofinity Medicare Advantage	$111.89
Rate for Payer: Encore Health Key Benefits Commercial	$127.87
Rate for Payer: Healthscope Commercial	$143.86
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$135.86
Rate for Payer: PHP Commercial	$135.86
Rate for Payer: Priority Health Cigna Priority Health	$103.90
Rate for Payer: Priority Health SBD	$100.70

GABAPENTIN 600 MG TABLET

Facility

$3.20

Service Code	NDC 50268035111
Hospital Charge Code	25855
Hospital Revenue Code	637
Min. Negotiated Rate	$2.02
Max. Negotiated Rate	$2.88
Rate for Payer: Aetna Commercial	$2.72
Rate for Payer: Aetna New Business (MI Preferred)	$2.08
Rate for Payer: Cash Price	$2.56
Rate for Payer: Cofinity Commercial	$2.24
Rate for Payer: Cofinity Commercial	$2.75
Rate for Payer: Cofinity Medicare Advantage	$2.24
Rate for Payer: Encore Health Key Benefits Commercial	$2.56
Rate for Payer: Healthscope Commercial	$2.88
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$2.72
Rate for Payer: PHP Commercial	$2.72
Rate for Payer: Priority Health Cigna Priority Health	$2.08
Rate for Payer: Priority Health SBD	$2.02

GABAPENTIN 600 MG TABLET

Facility

$2,209.00

Service Code	NDC 68462012605
Hospital Charge Code	25855
Hospital Revenue Code	637
Min. Negotiated Rate	$883.60
Max. Negotiated Rate	$1,988.10
Rate for Payer: Aetna Commercial	$1,877.65
Rate for Payer: Aetna Medicare	$1,104.50
Rate for Payer: Aetna New Business (MI Preferred)	$1,435.85
Rate for Payer: BCBS Complete	$883.60
Rate for Payer: Cash Price	$1,767.20
Rate for Payer: Cofinity Commercial	$1,546.30
Rate for Payer: Cofinity Commercial	$1,899.74
Rate for Payer: Cofinity Medicare Advantage	$1,546.30
Rate for Payer: Encore Health Key Benefits Commercial	$1,767.20
Rate for Payer: Healthscope Commercial	$1,988.10
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$1,877.65
Rate for Payer: PHP Commercial	$1,877.65
Rate for Payer: Priority Health Cigna Priority Health	$1,435.85
Rate for Payer: Priority Health SBD	$1,391.67

GABAPENTIN 600 MG TABLET

Facility

$3.20

Service Code	NDC 50268035111
Hospital Charge Code	25855
Hospital Revenue Code	637
Min. Negotiated Rate	$1.28
Max. Negotiated Rate	$2.88
Rate for Payer: Aetna Commercial	$2.72
Rate for Payer: Aetna Medicare	$1.60
Rate for Payer: Aetna New Business (MI Preferred)	$2.08
Rate for Payer: BCBS Complete	$1.28
Rate for Payer: Cash Price	$2.56
Rate for Payer: Cofinity Commercial	$2.24
Rate for Payer: Cofinity Commercial	$2.75
Rate for Payer: Cofinity Medicare Advantage	$2.24
Rate for Payer: Encore Health Key Benefits Commercial	$2.56
Rate for Payer: Healthscope Commercial	$2.88
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$2.72
Rate for Payer: PHP Commercial	$2.72
Rate for Payer: Priority Health Cigna Priority Health	$2.08
Rate for Payer: Priority Health SBD	$2.02

GABAPENTIN 600 MG TABLET

Facility

$228.00

Service Code	NDC 00904682361
Hospital Charge Code	25855
Hospital Revenue Code	637
Min. Negotiated Rate	$91.20
Max. Negotiated Rate	$205.20
Rate for Payer: Aetna Commercial	$193.80
Rate for Payer: Aetna Medicare	$114.00
Rate for Payer: Aetna New Business (MI Preferred)	$148.20
Rate for Payer: BCBS Complete	$91.20
Rate for Payer: Cash Price	$182.40
Rate for Payer: Cofinity Commercial	$159.60
Rate for Payer: Cofinity Commercial	$196.08
Rate for Payer: Cofinity Medicare Advantage	$159.60
Rate for Payer: Encore Health Key Benefits Commercial	$182.40
Rate for Payer: Healthscope Commercial	$205.20
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$193.80
Rate for Payer: PHP Commercial	$193.80
Rate for Payer: Priority Health Cigna Priority Health	$148.20
Rate for Payer: Priority Health SBD	$143.64

GABAPENTIN 600 MG TABLET

Facility

$2,209.00

Service Code	NDC 68462012605
Hospital Charge Code	25855
Hospital Revenue Code	637
Min. Negotiated Rate	$1,391.67
Max. Negotiated Rate	$1,988.10
Rate for Payer: Aetna Commercial	$1,877.65
Rate for Payer: Aetna New Business (MI Preferred)	$1,435.85
Rate for Payer: Cash Price	$1,767.20
Rate for Payer: Cofinity Commercial	$1,546.30
Rate for Payer: Cofinity Commercial	$1,899.74
Rate for Payer: Cofinity Medicare Advantage	$1,546.30
Rate for Payer: Encore Health Key Benefits Commercial	$1,767.20
Rate for Payer: Healthscope Commercial	$1,988.10
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$1,877.65
Rate for Payer: PHP Commercial	$1,877.65
Rate for Payer: Priority Health Cigna Priority Health	$1,435.85
Rate for Payer: Priority Health SBD	$1,391.67

GABAPENTIN 600 MG TABLET

Facility

$159.84

Service Code	NDC 50268035115
Hospital Charge Code	25855
Hospital Revenue Code	637
Min. Negotiated Rate	$63.94
Max. Negotiated Rate	$143.86
Rate for Payer: Aetna Commercial	$135.86
Rate for Payer: Aetna Medicare	$79.92
Rate for Payer: Aetna New Business (MI Preferred)	$103.90
Rate for Payer: BCBS Complete	$63.94
Rate for Payer: Cash Price	$127.87
Rate for Payer: Cofinity Commercial	$111.89
Rate for Payer: Cofinity Commercial	$137.46
Rate for Payer: Cofinity Medicare Advantage	$111.89
Rate for Payer: Encore Health Key Benefits Commercial	$127.87
Rate for Payer: Healthscope Commercial	$143.86
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$135.86
Rate for Payer: PHP Commercial	$135.86
Rate for Payer: Priority Health Cigna Priority Health	$103.90
Rate for Payer: Priority Health SBD	$100.70

GABAPENTIN 600 MG TABLET

Facility

$441.80

Service Code	NDC 68462012601
Hospital Charge Code	25855
Hospital Revenue Code	637
Min. Negotiated Rate	$278.33
Max. Negotiated Rate	$397.62
Rate for Payer: Aetna Commercial	$375.53
Rate for Payer: Aetna New Business (MI Preferred)	$287.17
Rate for Payer: Cash Price	$353.44
Rate for Payer: Cofinity Commercial	$309.26
Rate for Payer: Cofinity Commercial	$379.95
Rate for Payer: Cofinity Medicare Advantage	$309.26
Rate for Payer: Encore Health Key Benefits Commercial	$353.44
Rate for Payer: Healthscope Commercial	$397.62
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$375.53
Rate for Payer: PHP Commercial	$375.53
Rate for Payer: Priority Health Cigna Priority Health	$287.17
Rate for Payer: Priority Health SBD	$278.33

GADOBUTROL 10 MMOL/10 ML (1 MMOL/ML) INTRAVENOUS SOLUTION

Facility

$20.00

Service Code	HCPCS A9585
Hospital Charge Code	152500
Hospital Revenue Code	636
Min. Negotiated Rate	$12.60
Max. Negotiated Rate	$18.00
Rate for Payer: Aetna Commercial	$17.00
Rate for Payer: Aetna New Business (MI Preferred)	$13.00
Rate for Payer: Cash Price	$16.00
Rate for Payer: Cofinity Commercial	$14.00
Rate for Payer: Cofinity Commercial	$17.20
Rate for Payer: Cofinity Medicare Advantage	$14.00
Rate for Payer: Encore Health Key Benefits Commercial	$16.00
Rate for Payer: Healthscope Commercial	$18.00
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$17.00
Rate for Payer: PHP Commercial	$17.00
Rate for Payer: Priority Health Cigna Priority Health	$13.00
Rate for Payer: Priority Health SBD	$12.60

GADOBUTROL 10 MMOL/10 ML (1 MMOL/ML) INTRAVENOUS SOLUTION

Facility

$20.00

Service Code	HCPCS A9585
Hospital Charge Code	152500
Hospital Revenue Code	636
Min. Negotiated Rate	$8.00
Max. Negotiated Rate	$18.00
Rate for Payer: Aetna Commercial	$17.00
Rate for Payer: Aetna Medicare	$10.00
Rate for Payer: Aetna New Business (MI Preferred)	$13.00
Rate for Payer: BCBS Complete	$8.00
Rate for Payer: Cash Price	$16.00
Rate for Payer: Cofinity Commercial	$14.00
Rate for Payer: Cofinity Commercial	$17.20
Rate for Payer: Cofinity Medicare Advantage	$14.00
Rate for Payer: Encore Health Key Benefits Commercial	$16.00
Rate for Payer: Healthscope Commercial	$18.00
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$17.00
Rate for Payer: PHP Commercial	$17.00
Rate for Payer: Priority Health Cigna Priority Health	$13.00
Rate for Payer: Priority Health SBD	$12.60

Know your out-of-pocket cost for care.

All Charges